From their 2018 discussion on What’s New Under the Sun, Drs. Joely Kaufman, S. Manjula Jegasothy, Murad Alam, Michael Gold and Daniel Cassuto give insight to the new toxins and their potential uses, techniques and devices to look for in 2019.
The Future of Botulinum Toxins with Dr. Joely Kaufman
JK: We are going to start talking more about comparing each toxin based on a set endpoint, such as responder rate. According to the FDA, the responder rate would be someone who gets treated, and afterwards has a score of 0 or 1 on maxium glabellar frown score – basically the signs of how strong or weak the frown is. So if we want to start comparing these toxins, we’re going to have to start looking at that responder rate score and know what it looks like for each toxin in the periods of 4 to 24 weeks.
New on the horizon:
- DWP450/ Nabota/ Evolus / Prabotulinum toxin/ Jeuveau
- 900kDa molecule and has a similar responder rate as Onabotulinum
- Rumor is will come to market at a less expensive price than Botox (however, this may be after discounts)
- Croma/Hugel with Botulax/ Letibotulinum toxin A
- Phase 3 trials
- Results aren’t published
- Liquid toxins
- Innatox from Meditox, Allergan acquired to sell
- Just beginning phase 3 trials in US
- Ipsen conducting trials with liquid toxin ASI (Abobotulinum Solution for Injection)
- RT002 Daxibotulinum toxin from Revance
- 150 kd toxin with proprietary peptide
- Phase 3 trails complete
- Non – A1 toxins
- BoNT/E (Bonti)
- Purchased by Allergan
- Fast onset, short acting
- Possible use for pain, scars or someone who is new to aesthetics
- BoNT/E (Bonti)
- BNT- A2
- Animals studies show to be more potent than BoNT-A1
How will physicians differentiate these toxins? Dr. Kaufman says it’s the phase 4 data and physician’s clinical use that makes the understanding so reliable and informational about what these toxins can do and how they function because they are all a little different.
JK: The nice thing is you can go online and see every single trial that’s being conducted in the US on www. Clinicaltrials.gov. If you’re interested in a topic, you can type in a word and it’ll list who’s enrolling, end points and the patients enrolled. The website is a nice way to keep up with the technology that’s coming to our market.
Finding New Ways to Treat with Ulthera, PRP and Lasers with Dr. S. Manjula Jegasothy
Following company and charging guidelines with the Ulthera’s high frequency ultra sound machine, Dr. Manjula Jegasothy found she was only using her Ulthera device once or twice a week. In order to get the most out of her machine, she developed the “Ulthera Mini lift.” In her practice today, she performs the “Ulthera Mini Lift” about five to six times a day with focus on the given areas such as the jowls, jawlines or eyelids. Her patients are coming back to her office more frequently because they’re seeing great results.
MJ: I’m doing it on the eyelids, particularly in younger patients. If they fail radio frequency, then I’ll treat the eyelids with combination of RF and Ulthera for tightening.
Dr. Jegasothy has occasionally noticed about five to six hours after Ulthera, some patients get the ‘stripe phenomena’ where there stripes appear in the area of treatment. She can’t predict who will get the stripe phenomena but she always uses a Class 1 steroid after Ulthera because it helps prevent stripes from appearing. If and when the stripes occur, she treats the issue with Zyrtec and a topical OTC hydrocortisone. She says adding an oral antihistamine can really help.
For patients who aren’t getting the best results with Fraxel and Vbeam treatments for striae, Dr. Jegasothy has started treating striae with PRP. She performs the laser treatments first and then two to three months later, she does PRP. She treated a patient whose distended striae looked similar to hypertrophic scars. Dr. Jegasothy was able to flatten the stubborn straie to look more normal with PRP.
Treating early lentigines and new melasma with light Erbuim Fractional Laser has been one of Dr. Jegasothy’s favorite things to do in the last year. She finds the majority of her patients don’t want the four to five day recovery associated with the ND:YAG so using a light Fraxel at different settings has been a great solution for minimal downtime. For full face rejuvenation, she starts with settings at 20/10 or 20/8 and always staying very light. Then, she’ll perform multiple passes at ever-reducing depths of the penetration wells.
MJ: You can actually see when you’ve treated the pigmentation or what you’ve taken care of at the level where the issue exists in the dermis or at the dermal epidermal junction. The Fraxel has become a more of a diagnostic tool for me in terms of realizing where pigmentation can be found in the skin. I always tell my patients this is why it’s great to come to a board-certified dermatologist for laser treatments because we have a better understanding of the pathology and histology of the skin.
Potential uses for Type E Botulinum Toxins with Dr. Murad Alam
Type E toxin is different than type A toxin due to the very rapid on set of action within 24 hours, but stops working in a couple of weeks. Dr. Murad Alam takes a look at short acting type E toxin (Bonti) and its potential use for scars.
MA: Our thesis was if the period of time the scar was mostly remodeling (right after suture) for the first two weeks while stitches were in, if you could take some tension off with a NT, would that make it look nicer? It was a small, randomized control pilot study that looked at 12 patients (8 active, 4 placebos) and each case had a closure of at least 2cm on the forehead. We thought of using the forehead as it was a relatively uncomplicated area where there is only the frontalis – one muscle all in the same direction.
Dr. Alam says there were two categories of patients based on whether their closure was vertical or horizontal. The outcome showed that on day 30, toxins looked better. Then on day 90, the scars looked back to normal for both groups. By at the end of the study, the results of the scars all looked pretty similar.
MA: Keep in mind though, that for patients who are getting closures on their face, even if they look good on day 90, they’re pretty unhappy if they look horrible during the two weeks post treatment. I do think we are potentially doing a service for these patients if we take away the bad short term look.
Overall, patients treated with the toxin were not bothered by any itch from scar site, 75% of the pain scores were better, less red color and stiffness and improvement in the interim period. The appearance got better a little faster in the toxin case.
MA: We will be doing more studies of specific indication for which product is best used through studies in order to differentiate those benefits. I think this is the move to personalized medicine but it’s also the move to specialized products and how to tailor them to specific patients.
At-Home Devices and Long Term IPL with Dr. Michael Gold
Studies have been done to evaluate whether the skin will look better as it ages with a minimum of 8 year treatments with broadband light (BBL) treatment. With the help of Dr. Ping Chen, Dr. Gold took it the data a step further and conducted a study with 2,500 patients who had at least 3 or more IPL treatments every year for at least 10-15 years. The results were outstanding.
MG: Recurrent IPL rejuvenation is real. If you do this, the long term makes your skin look younger. It’s proven and something you should consider. A lot of us will do IPL for two or three treatments and then we’re finished. Schedule them to come back and maintain this. We have data showing changes that actually make skin look younger.
Dr. Gold breaks down the top three at-home devices to look out for this year.
- Clarisonic is back with the MIA smart device. Dr. Gold was a part of a cohort study done with the MIA Smart and the results show 50 subjects with moderate to severe acne that now have minimal acne.
- Joli360 is a ‘smart’ home device for skin rejuvenation. This company does not exist in this country but it’s coming to the U.S. Joli360 is going to work to do RF, electroporation and much more. It’s all going to be connected to an app that will tell us how to use it.
- vSculpt is a home device that tones, tightens, and restores the vaginal tissue and muscles of the pelvic floor. Backed with massive studies, this device is economical, costing a third of what women spend annually on pads.
MG: Vaginal rejuvenation is the real deal. This is an issue people need to get treated whether it’s urinary incontinence, vaginal dryness or pain with intercourse. Use it 10 minutes a day, every other day for 6 weeks. Its home-use ensures privacy and ease.
Jet Volumetric Remodeling (JVR) with Dr. Daniel Cassuto
Jet Volumetric Remodeling (JVR) is a needle-free, proprietary technology that simultaneously delivers kinetic energy and a healing compound, enabling a controlled, deep micro-trauma profile effect for dermal remodeling. The nanoscopic jet entry to collagen fibers promotes regeneration below the inflammatory threshold.
DC: This is a delivery system that can inject anything you wish. It happens without a needle but unlike any derma pen or many of those hand held needleless injection devices, the pressure generated in JVR is very, very high – it’s about 100 times more. There are different kinds of evidence today that show HA does promote elastin and new collagen. Doubling collagen fibers is very reproducible with this technology. We inject a diluted HA is which is diluted about 5 times more than a filler.
JVR is more precise than anything you do manually. You can inject depth from 6 mm to 0.6 mm. Many things can be injected this way, including hyaluronic acid fillers. The device does not come with any injectable product and leaves it entirely in the hands of the practitioner.
DC: This has removed all other energy based devices in my practice. Hyaluronic acid has a lot of important roles. I’ve begun to use them on burn patients who are tired of Z-plastys and skin grafts. The Enerjet is now FDA approved. Ongoing studies are conferming its efficacy on many kinds of scars, especially acne scars of all shapes and depths.
JVR is useful treatment for striae, acne scars (faster than subcision), stretch marks and burn-scar patients.
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